Citation Nr: 1132012 Decision Date: 08/31/11 Archive Date: 09/07/11 DOCKET NO. 06-00 338 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection under the provisions of 38 U.S.C.A. § 1151 for residuals of coronary artery bypass graft surgery including an infection of the sternum resulting in a sternotomy, scars, muscle loss and atrophy. 2. Entitlement to service connection for an acquired psychiatric disorder including under the provisions of 38 U.S.C.A. § 1151 or as secondary to residuals of a coronary artery bypass surgery. 3. Entitlement to a total rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant; Appellant's spouse and son ATTORNEY FOR THE BOARD John Francis, Counsel INTRODUCTION The Veteran served on active duty from June 1969 to March 1973. This appeal comes before the Board of Veterans' Appeals (Board) from March 2004 and May 2007 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board sitting at the RO in February 2010. A transcript of the hearing is associated with the claims file. The issues of service connection for an acquired psychiatric disorder and for a total rating based on individual unemployability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC) in Washington, D.C. FINDINGS OF FACT 1. An additional cardiovascular disability was not caused by VA hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by VA medical inpatient or outpatient care. 2. A Methicillin-resistant staphylococcus aureus (MRSA) infection of the sternum leading to debridement, a sternotomy, and a pectoral muscle flap reconstruction was incurred during VA inpatient medical treatment and was an event not reasonably foreseeable. CONCLUSION OF LAW The criteria for service connection for residuals of an infection of the sternum resulting in a sternotomy, scars, muscle loss and atrophy have been met. 38 U.S.C.A. § 1151 (West 2002); 38 C.F.R. §§ 3.361, 17.32 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2010). In this case, the Board is granting in full the benefit sought on appeal. Accordingly, assuming, without deciding, that any error was committed with respect to either the duty to notify or the duty to assist, such error was harmless and will not be further discussed. The Veteran served the U.S. Coast Guard with duties involving port security. In November 2002, the Veteran underwent coronary artery bypass graft (CABG) surgery at a VA Medical Center. He subsequently experienced suture failure and wound dehiscence which required additional surgical procedures for debridement of the sternum, a pectoral muscle flap reconstruction, and treatment for a staphylococcus infection. He contends that residuals of this treatment caused an additional disability that warrants service connection under the provisions of 38 U.S.C.A. § 1151. Effective for claims received on or after October 1, 1997, an additional disability is a qualifying disability if it was not the result of the veteran's willful misconduct, the disability was caused by VA hospital care, medical or surgical treatment, or examination furnished the veteran under any law administered by the VA, and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination; or was an event not reasonably foreseeable. 38 U.S.C.A. § 1151(a). In determining whether a veteran has an additional disability, VA compares the veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the veteran's condition after care or treatment is rendered. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the veteran's additional disability. Merely showing that a veteran received care or treatment and that the veteran has an additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a veteran's additional disability, it must be shown that the hospital care or medical or surgical treatment caused the veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) VA furnished the hospital care or medical or surgical treatment without the veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). In several written statements and in testimony at a February 2010 Board hearing, the Veteran described the events leading to, during, and after CABG surgery in November 2002. At that time, the Veteran had the following service-connected disabilities: postoperative meniscal and ligament tears of the right knee, rated as 30 percent disabling and degenerative joint disease of the right knee, rated as 20 percent disabling. The Veteran also had been diagnosed with the following non-service-connected disorders: diabetes mellitus, hypertension, hyperlipedemia, obesity, peptic ulcer disease, necrosis of the right hip, and residuals of a fracture of the right humerus with lower right extremity neuropathy. The Veteran reported to clinicians that the latter disorder had resolved before 2002. The Veteran reported that he sought treatment for left shoulder, middle back, and chest pain in August 2002. He contended that his symptoms were misdiagnosed as bursitis by a VA clinician which delayed the identification of coronary artery disease. He reported that he was admitted to a VA Medical Center in late October 2002 for increasing chest pain on exertion. The Veteran reported that he underwent a three way CABG without receiving antibiotic medication including at the time of discharge when he was experiencing a fever and cough. He reported that he developed a staphylococcus infection of the sternum during the course of treatment. He further reported that he experienced surgical wound dehiscence and did not receive prompt treatment which caused great pain and emotional stress. He reported that he waited for six hours on one day for suture removal that did not take place. On the next day, sutures were removed leaving a dehiscent wound and that he was not admitted to the hospital or received any treatment until the following day. Additional surgery was necessary to debride the sternum infection and to perform a pectoral muscle flap reconstruction. He reported that he developed post-surgical neuropathy of his right arm and was placed in an isolation ward because of the staph infection. VA outpatient treatment records showed that the Veteran received periodic primary care assessments in 2001-2002. Clinicians noted the Veteran's reports of occasional shoulder pain but no chest pain or shortness of breath. The Veteran was advised to exercise to lose weight, reduce alcohol intake, and cease smoking. The Veteran sought treatment in August 2002 for left shoulder, chest, and upper back pain that he had experienced for the previous week. Veteran reported that the pain was more severe in the mornings but that he did not experience shortness of breath. The Veteran reported that he had not experienced any trauma but had been doing extra work as a window washer. On examination, a physician's assistant (PA) noted anterior left shoulder tenderness on abduction and rotation with no pulmonary or heart deficits. The PA diagnosed bursitis and prescribed medication. In late October 2002, the Veteran sought treatment at a VA urgent care clinic for left sided chest pain that he had experienced intermittently for the past four weeks with increasing frequency and lasting up to one hour while hiking. The pain occasionally radiated to the left shoulder and was associated with nausea and shortness of breath. The Veteran was admitted to the Medical Center for testing. The admitting physician noted the Veteran's reports of intermittent pain since June. The Veteran had several risk factors but no previous history of coronary artery disease. The Veteran underwent cardiac catheterization that showed severe three- vessel coronary artery disease. Five days later, the Veteran underwent a three vessel CABG surgery. Consent for the surgery was obtained, and a copy of a consent form signed by the Veteran is of record. The Veteran acknowledged that there was no guarantee concerning the results and that the attendant risks and complications included infection, pain, bleeding, prolonged time of intubation, damage to surrounding structures, and the need for further procedures. VA hospital records showed that intravenous antibiotics were ordered and "taped to the chart" prior to the surgery and that intravenous antibiotics including cefazolin and vancomycin were administered immediately after surgery and continued through to the second day. The attending surgeon noted that the Veteran was transferred after surgery to an intensive care unit in critical but stable condition with no complications. Two and three days following the surgery, a VA nurse noted no symptoms or signs of wound infection. Four days after surgery, a nurse noted that the Veteran expressed a desire to go home. There were no symptoms or signs of infection and no reports of a cough. The Veteran was instructed on the symptoms that would indicate infection or the need for immediate treatment. The Veteran was not prescribed oral antibiotics at the time of discharge. Three days after discharge from the hospital, the Veteran sought treatment at the urgent care clinic for symptoms of chills and a low fever that started a few hours earlier. A physician examined the Veteran and noted no infection at the sites of the surgical wounds and diagnosed possible anemia or pneumonia. No additional medication was prescribed. It is not clear whether the times of day shown in the records are the times for observation and treatment or the time of entry in the records by the clinicians. Just after midnight on day 13 after surgery, the VA outpatient records showed that the Veteran sought treatment at the urgent care clinic for discomfort and swelling above the CABG incision that he first noticed at about 6:30 pm. The swelling was not tender, but there was some discomfort along the right upper chest with radiation down the right arm with movement. There was no fever. The examining physician noted that the symptoms could represent local irritation or a superior sternum wire break. However, the physician concluded that the Veteran's chest wall was stable and that no urgent therapy was needed. The Veteran was prescribed oral antibiotics with the last treatment record entry at approximately 1:30 am. The Veteran returned to the clinic at approximately noon the same day for a previous appointment to remove sutures. A nurse noted that the Veteran's physician was out of town and that the Veteran should return to the thoracic surgery unit the next day. The last treatment record entry was at approximately 1:15 pm with a continued listing for oral antibiotics. In the early afternoon of day 14 following surgery, the Veteran reported to the surgery clinic. A surgical resident physician noted the record of the swelling from the previous day and noted no obvious crepitus or sternum instability. Upon removal of staples, the wound oozed approximately 50 cubic centimeters (cc) of blood. The physician admitted the Veteran to the hospital for observation, treatment of a possible wound dehiscence, and a chest X-ray. About 45 minutes later, the Veteran's surgeon examined the wound and noted no sternum instability or firm evidence of wound dehiscence and ordered the application of a pressure dressing. Records showed entries throughout the afternoon and evening of administration of medication and the evening meal. In mid-evening, a resident physician noted no chest pain except for pectoral muscles on movement and no purulent drainage. The chest X-ray showed the sternum intact with one broken wire. The resident noted that the Veteran had been admitted for dehiscence of skin and subcutaneous tissue and would be under observation until the next day to assess sternum stability. The next morning, the Veteran's surgeon noted significantly more drainage and the Veteran's report of overnight sternum "cracking" indicative of instability. The wound had further dehisced to the level of the sternum. The surgeon directed that the Veteran be taken to the operating room for exploration and probable sternum debridement. A surgical resident noted that two wires were torn through the sternum on the right side and one wire was broken, but that the sternum was not "grossly infected." Debridement of the sternum was accomplished with specimen taken for culture, and the wound was packed pending an assessment for plastic surgery. Another surgical resident noted that impaired wound healing was secondary to the Veteran's diabetes mellitus and coughing. A pectoral muscle flap reconstruction was performed the next day. The Veteran reported numbness in the right fingers and was diagnosed with right ulnar neuropraxia. Two days later, cultures were found to be positive for a Methicillin-resistant staphylococcus aureus (MRSA) infection, and the Veteran was place in an isolation setting and prescribed course of various antibiotics. The Veteran was eventually discharged from the hospital in early December 2002 with drains in place and continued antibiotic medications. In January 2003 and July 2003, the Veteran underwent electrodiagnosic studies that confirmed profound subacute right ulnar neuropathy. In August and October 2003, VA clinicians concluded that the right arm nerve injury that he incurred in 1992 had resolved and that the current disorder was a residual of the pectoral muscle flap reconstruction. In May 2004, a VA neurologist reviewed the electronic medical records, examined the Veteran, and noted the same conclusions. In June 2004, the RO granted service connection under 38 U.S.C.A. § 1151 for right ulnar neuropathy. In April 2009, a VA osteopathic physician at a different VA Medical Center noted a review of the claims file including the history of treatment and surgery for coronary artery disease. The Veteran reported that he had experienced a myocardial infarction in 2002 that is inconsistent with the VA records. The physician noted that the Veteran underwent a persatine thallium stress test in June 2008 that was a normal study with an ejection fraction of 75 percent. The Veteran reported that he experience chronic chest wall pain at the site of the surgical scar and that the scars were annoying but not tender. The Veteran also reported fatigue and shortness of breath on mild exertion. On examination, the physician noted scars from the sternotomy, pectoral flap reconstruction, drains, and right arm and shoulder, the latter associated with the 1993 fracture. None of the scars were tender. The physician observed cardiac pulsations in the area of the sternotomy scar and a palpable sternum defect. The physician noted that another exercise stress test was not indicated because of the Veteran's overall general poor health and orthopedic problems. Based on the Veteran's description of his activities, the physician estimated a metabolic equivalent of five. After review of the treatment records, the physician noted, "I was unable to find any evidence of fault on the part of the VA in furnishing the hospital care, medical, or surgical treatment." The physician further noted, "This is an event not reasonable (sic) foreseen, although, it is a rare complication of CABG surgery." Two weeks later in April 2009, the Veteran was examined by a VA PA who noted a review of the claims file including the records of coronary artery disease treatment and the Veteran's accounts of that treatment. The Veteran reported that his current symptoms included midline chest pain, rubbing of the ribs when taking a deep breath, popping sounds that disturb sleep, and chest pains when attempting to lift, pull, or push with his arms. On examination, the PA provided a description of the scars. Color photographs are associated with the claims file. The PA noted free mobility of the chest wall, crepitus, and asymmetry of motion with deep breathing, all consistent with a sternotomy. X-rays showed a normal heart size with soft tissue swelling on the anterior of the chest wall. The sternum was not adequately visualized. The PA noted that unidentified medical literature sources showed that a sternotomy after medistinitis, dehiscence of an anterior chest wall incision, and infection are known complications that are significantly higher in immunocompromised patients especially overweight diabetics. The PA concluded that the scars, atrophy, and loss of sternum were not due to carelessness, negligence, lack of proper skill, error in judgment or similar instances of fault on the part of VA in furnishing hospital care because the residuals were known complications of CABG surgery especially in diabetic and overweight patients. The osteopathic physician electronically countersigned the report. In a February 2010 Board hearing, the Veteran described his experiences at the VA hospital from October to December 2002. He stated that he did not receive antibiotics at the time of discharge after surgery despite a fever and cough. He stated that he was not admitted to the hospital when his surgical wound dehisced but was left in a room overnight with little care. He stated that there were construction activities in progress inside the hospital during this time. The Veteran described his current symptoms of pain, crunching discomfort in his ribs, abnormal movement of the diaphragm, and cessation of breathing at night. The Veteran stated that he continued to drive an automobile against the orders of his physician. In May 2011, the Board requested an independent medical opinion from a physician at a university school of medicine. The Board provided the entire claims file for review and posed the following questions: 1. Were the Veteran's surgical wound dehiscence, bacterial infection, and excision of the sternum proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination after CABG surgery in November 2002; or were these events proximately caused by an event not reasonably foreseeable? 2. Did the Veteran sustain an additional cardiovascular disability as a consequence of CABG surgery in November 2002? If so, were any additional disabilities proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the VA in furnishing the hospital care, medical or surgical treatment, or examination; or by an event not reasonably foreseeable; or were these disabilities the normal progression of the Veteran's disease? In May 2011, the university physician noted a review of unspecified medical literature and that sternum wound infection is a known complication of CABG surgery that occurs in approximately two percent of patients. He noted that the antibiotic cephazolin was the preferred choice for antibiotic prophylaxis prior to surgery. He further noted that the Veteran did not have symptoms of infection at the time of his discharge to home four days after surgery and that antibiotics at that point in time were not medically indicated. The physician noted that it was not obvious on his review that antibiotics were administered within one hour of surgery, but that if the antibiotic were administered, there was no degree of medical negligence on the part of VA or any additional cardiovascular disability as a result of CABG surgery. Comparing the Veteran's medical condition before and after VA treatment from August 2002 to December 2002, the Board concludes that the Veteran did incur an additional disability as a result of VA medical care. The additional disability is the residual symptoms caused by a sternotomy or sternum debridement and the muscle flap reconstruction. The Veteran's sternum structure and right pectoral muscle were intact, not infected, and orthopedically functional prior to the treatment. The bone structure was removed to excise infected areas and the muscle tissue relocated to protect the chest cavity. The Veteran experiences pain, rib contact, diaphragm dislocations, and limitations in upper body functions as a result of the surgical procedures. The Board concludes that service connection under the provisions of 38 U.S.C.A. § 1151 is warranted for those residual symptoms directly related to the sternotomy or sternum debridement and pectoral muscle flap reconstruction. The Board places greatest probative weight on the opinions of the VA physician in 2009 and the independent university physician in 2011 who reviewed the Veteran's contentions and the detailed hospital records and concluded that the Veteran's surgical wound dehiscence, bacterial infection, and excision of the sternum were not proximately caused by carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care, medical or surgical treatment, or examination after CABG surgery in November 2002. The physician's noted that infection, though rare, is a complication of CABG surgery. The Veteran was advised and acknowledged the possibility of this complication in a consent form prior to the surgery. There are medical records that show that intravenous antibiotics were ordered prior to and after surgery and that the Veteran was discharged with no cough, fever, or observations by clinicians of wound site infection or instability. Contrary to the Veteran's contention of inadequate care after dehiscence of his wound, the medical records showed that the initial dehiscence was in surface tissue, an X-ray was taken, and he was admitted overnight under observation by a resident physician. When the condition of the wound deteriorated overnight, he was moved immediately into surgery. Even though wound infection is a foreseeable risk, the Board concludes that the incurrence of an antibiotic-resistant staphylococcus infection to the extent that the sternum required extensive debridement and muscle reconstruction is an event that is not reasonably foreseeable. The Board acknowledges the opinions of two physicians that the poor sternum healing was related to the Veteran's compromised immune system from diabetes and additionally affected by obesity. It is reasonably foreseeable that the Veteran's wire sutures fractured. The Veteran's cough symptoms were not evident when he was discharged after surgery, developed at home, and were not presented to clinicians until he returned to the hospital for suture removal. These symptoms were concurrent with the swelling and ultimate fracture of the wire sutures. Therefore, the wound dehiscence was also reasonably foreseeable. However, the Board concludes that the nature of antibiotic resistant staplococcus infection and the extent of that infection which led to an extensive debridement of the sternum and muscle reconstruction were not reasonable foreseeable. Because the Veteran never had an open wound outside the VA facility, the resistant bacteria strain was likely incurred while under VA hospital treatment. Although the Veteran was provided with prophylactic antibiotics prior to surgery and as later indicated by his symptoms, the alternative antibiotics effective against a MRSA infection were not employed until after that infection was identified, thus demonstrating that this unusual infection was unforeseen. Following a laboratory determination, the Veteran required isolation from other patients. In order to gage what a reasonable health care professional would consider reasonably foreseeable, the Board places greatest probative weight on the opinion of the VA physician in 2009. Although he did not find negligence or error, he concluded that the nature and extent of the infection was not reasonably foreseeable. No other clinician or consulting physician considered a sternotomy caused by a MRSA infection to be a reasonably foreseeable consequence of CABG surgery. The Board further concludes that the Veteran did not incur an additional cardiovascular disability as a result of VA medical care. The Board acknowledges the Veteran's contention that his cardiovascular disease should have been diagnosed in August 2002, several months before its diagnosis in October 2002. As diagnosis of a complex cardiovascular deficiency requires medical expertise, the Board concludes that the Veteran is not competent to provide an opinion on this issue. The symptoms reported by the Veteran to a VA clinician in August 2002 were not those he reported to clinicians in October 2002. At the earlier encounter, the Veteran reported chest, upper back, and shoulder pain for one week after performing a greater than usual amount of physical labor as a window washer. The Veteran had a history of shoulder discomfort at that time. He did not report other symptoms such as fatigue or shortness of breath. He did not reveal to the clinician that he had been experiencing intermittent chest pains on exertion since June. The Veteran reported these symptoms in full only in October 2002 and those reports were immediately investigated in a cardiac catheterization. Moreover, the Veteran had many long term risk factors such as diabetes, obesity, alcohol, and tobacco use. The Veteran's report of a myocardial infarction in 2002 is not credible as he never reported this to his treating clinicians and the event is not noted in any medical record. There is no medical evidence to show that he incurred an additional disability or aggravation of coronary artery disease because of a perceived delay in care. Finally, despite the ensuing sternum infection, the CABG was successful in opening the restricted coronary arteries. None of the post-surgery clinicians or physicians providing medical opinions indicated that the Veteran's current cardiovascular symptoms were caused by errors in VA medical care and not a normal progression of his disease. Therefore, service connection for cardiovascular disease under the provisions of 38 U.S.C.A. § 1151 is not warranted. Therefore, and to this extent only, the Board grants service connection under the provisions of 38 U.S.C.A. § 1151 for residual symptoms and incapacity arising from a sternotomy and pectoral muscle flap reconstruction but not for cardiovascular or coronary artery disease. ORDER Service connection under the provisions of 38 U.S.C.A. § 1151 for residuals of an infection of the sternum resulting in a sternotomy, scars, muscle loss and atrophy is granted, subject to the legal criteria governing the payment of monetary benefits. REMAND The Veteran contends that he experiences an acquired psychiatric disorder, diagnosed as major depression and posttraumatic stress disorder, as a result of his experiences during the VA hospital treatment and surgery for coronary artery disease from October to December 2002. In statements in October 2006, August 2007, September 2008, and June 2009, the Veteran reported that he experiences episodes of sweating, panic attacks, nightmares, intrusive thoughts, insomnia, tremors, loss of concentration, social isolation, and sensitivity to loud noise. The Veteran associated these symptoms with traumatic experiences in the VA hospital as discussed above during the 18 hours between the start of his wound dehiscence and the start of corrective surgery to debride an infection of the sternum the next day. He reported severe pain, frustration with lack of care, and fear of death. The file contains August 2007 statements by family members and a friend who witnessed and described his experiences in the hospital. In a February 2010 Board hearing, the Veteran stated that he was not receiving regular psychiatric treatment but was referred to a VA psychologist on an infrequent basis and was prescribed medication for sleep. There are no records of VA psychiatric care in the claims file. In letters in August 2006 and September 2006, a private psychiatrist noted that the Veteran suffers from major depression and PTSD due to his CABG wound dehiscence and surgeries. The letter contains no clinical assessment of symptoms or rationale, and no clinical records have been obtained. VA outpatient treatment records from 2003 to 2006 show prescriptions for an anti-depressive medication with no related clinical comments or diagnoses. In April 2006, the Veteran's VA primary care physician declined to sign a letter prepared by a counselor confirming a diagnosis of PTSD related to an unhealed sternotomy incision. On several occasions, in routine screenings by primary care clinicians, the Veteran denied any psychiatric symptoms or traumatic events. In December 2008, the physician noted the Veteran's reports of symptoms of depression once per week when he was having a bad day. Records of private and VA psychiatric care have not been obtained. Primary care records do not reflect the nature and extent of the mental health symptoms as described by the Veteran in his correspondence to adjudicators. Therefore, the Board concludes that additional medical records and an examination are necessary to decide the claim. 38 C.F.R. § 3.159 (c). The Veteran has not been evaluated to determine whether his service-connected disabilities alone preclude all forms of substantially gainful employment. Moreover, as the issue of service connection for an acquired psychiatric disorder is intertwined with the claim for a TDIU, the Board will defer a decision on this issue pending further development. Accordingly, the case is REMANDED for the following action: 1. Request from the Veteran authorization to obtain clinical records of psychiatric care from the private psychiatrist who provided letter opinions in August and September 2006. If authorized, request all records of clinical psychiatric care and associate any record received with the claims file. 2. Request from the Veteran the identity and location of the VA psychologist who provided mental health care as he reported at his February 2011 Board hearing. Request records of this VA care since 2002 and in any event request all records of VA outpatient treatment since January 2009. Associate any records received with the claims file. 3. Then, schedule the Veteran for a VA mental health examination by a psychiatrist or doctoral-level psychologist. Request that the examiner review the claims file and note the review in the examination report. a. Request that the examiner assess the Veteran's mental health status and provide an opinion whether any acquired psychiatric disorder is at least as likely as not (50 percent possibility or greater) related to the Veteran's experiences associated with the incurrence of a MRSA infection of the sternum, muscle flap reconstruction, or any residual disabilities associated with these deficits. The examiner should distinguish causation from these aspects of the Veteran's VA hospital treatment in 2002 from other aspects related only to coronary artery disease. b. Request that the examiner provide an opinion if an acquired psychiatric disorder, if any, precludes the Veteran from securing or pursuing all forms of substantially gainful employment. 3. Then, schedule the Veteran for a VA orthopedic examination. Request that the examiner assess the severity of the Veteran's service-connected right knee, sternum deficits, and pectoral muscle flap reconstruction disabilities. Request that the examiner provide an opinion whether these disabilities preclude all forms of substantially gainful employment without consideration of non-service-connected diabetes mellitus, hypertension, hyperlipedemia, obesity, peptic ulcer disease, necrosis of the right hip, residuals of a fracture of the right humerus with lower right extremity neuropathy. 4. Review the claims file to ensure that all the foregoing requested development is completed, and arrange for any additional development indicated. Then, readjudicate the claim for service connection under the provisions of 38 U.S.C.A. § 1151 for an acquired psychiatric disorder and for a total rating based on individual unemployability. If any benefit sought remains denied, the RO should issue an appropriate supplemental statement of the case and provide the appellant and his representative the requisite time period to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. The purpose of this remand is to assist the appellant with the development of his claims. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the appellant until further notice. However, the Board takes this opportunity to advise the appellant that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claims, including reporting for any scheduled VA examination, is both critical and appreciated. The appellant is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2010). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. 38 U.S.C.A. §§ 5109B, 7112 (West 2002 & Supp. 2009). ______________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs